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| Color Doppler ultrasound imaging in varicoceles: Is the difference in venous diameter encountered during Valsalva predictive of palpable varicocele grade? |
Kelly Lehner*( ),Catherine Ingram,Utsav Bansal,Colleen Baca,Adithya Balasubramanian,Nannan Thirumavalavan,Jason M. Scovell,Saneal Rajanahally,Matthew Pollard,Larry I. Lipshultz
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| Baylor College of Medicine, Scott Department of Urology, Houston, TX, USA |
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Abstract Objective: The clinical grading system for varicoceles is subjective and dependent on clinician experience. Color Doppler ultrasound (US) has not been standardized in the diagnosis of varicoceles. We aimed to determine if US measurement of varicocele could be predictive of World Health Organization (WHO) varicocele grade. Methods: Men who presented for either scrotal pain or infertility to a tertiary men's health clinic underwent physical examination, and varicoceles were graded following WHO criteria (0=subclinical, 1, 2, 3). US was used to measure largest venous diameter in the pampiniform plexus bilaterally at rest and during Valsalva maneuver. Receiver operator characteristic curve analysis was used to determine if resting diameter, diameter during Valsalva, or change in diameter between at rest and during Valsalva provided the highest sensitivity and specificity for determining clinical grade. Threshold values for diameter were determined from these receiver operator characteristic curves. Results: A total of 102 men (50 with clinical varicocele and 52 with subclinical varicocele) were included. Diameter at rest was the best ultrasonographic discriminator between subclinical and clinical varicoceles (area under the curve [AUC]=0.67) with a diameter threshold of 3.0 mm (sensitivity 79%, specificity 42%). Diameter during Valsalva had the greatest AUC for determining clinical Grades 1 versus 2 (AUC=0.57) with diameter threshold of 5.7 mm (sensitivity 71%, specificity 33%). For differentiating between Grades 2 and 3, diameter at rest had the greatest AUC of 0.65 with a threshold of 3.6 mm (sensitivity 71%, specificity 58%). Conclusion: Our results corroborate other studies that have shown a weak correlation between US and clinical grading. The use of diameter during Valsalva was less predictive than diameter at rest and was only clinically significant in differentiating between Grade 1 and 2 varicocele. A standardized method for determining clinically relevant varicoceles on US would allow for improved patient counseling and clinical decision-making.
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Received: 12 June 2020
Available online: 20 January 2023
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Corresponding Authors:
Kelly Lehner
E-mail: kellypayne1313@gmail.com
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| Characteristic | Value | | Age, year | | Mean±SD | 34±7 | | Range | 15-57 | | Reason for presentation, n | | Pain | 8 | | Infertility | 94 | | BMI, kg/m2 | | Mean±SD | 30.4±9.1 | | Range | 19.3-88.0 | | Left testicle clinical grade, n | | 0 | 52 | | 1 | 12 | | 2 | 31 | | 3 | 7 | | Right testicle clinical gradea, n | | 0 | 52 | | 1 | 19 | | 2 | 25 | | 3 | 1 |
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Patient demographics (n=102).
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| Clinical grade | At rest | During Valsalva | Difference between means | | Mean±SD | Range | Mean±SD | Range | | Grade 0 (n=52) | 3.12±0.98 | 0-5.2 | 4.46±1.52 | 2.2-10.3 | 1.34 | | Grade 1 (n=12) | 3.71±0.88 | 2.4-5.6 | 4.86±1.42 | 3.4-7.5 | 1.15 | | Grade 2 (n=31) | 3.89±1.56 | 1.3-7.6 | 4.84±2.62 | 0-14.2 | 0.94 | | Grade 3 (n=7) | 4.60±1.74 | 2.7-8.1 | 4.96±1.97 | 2.7-8.8 | 0.36 | | Total (n=102) | 3.52±1.30 | 0-8.1 | 4.65±1.92 | 0-14.2 | 1.13 | | p-Value | 0.004 | | 0.776 | | |
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Comparison of left scrotal ultrasound diameter measurements (mm) at rest and during Valsalva between different varicocele grades.
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| Clinical grade | At rest | During Valsalva | Difference between means | | Mean±SD | Range | Mean±SD | Range | | Grade 0 (n=52) | 3.04±1.18 | 0-6.2 | 4.14±1.21 | 2.1-6.9 | 1.1 | | Grade 1 (n=19) | 2.98±1.07 | 0-5.3 | 4.20±1.17 | 2.4-6.0 | 1.22 | | Grade 2 (n=20) | 3.39±0.92 | 1.4-4.8 | 4.14±0.99 | 2.2-5.6 | 0.75 | | Grade 3 (n=11) | 3.75±1.41 | 2.2-6.7 | 3.95±1.64 | 2.1-8.1 | 0.5 | | Total (n=102) | 3.18±1.15 | 0-6.7 | 4.13±1.20 | 2.1-8.1 | 0.95 | | p-Value | 0.202 | | 0.961 | | |
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Comparison of right scrotal ultrasound diameter measurements (mm) at rest and during Valsalva between different varicocele grades.
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Left testicle ultrasound maximum venous diameter at rest, during Valsalva, and the difference between the two.
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Right testicle ultrasound maximum venous diameter at rest, during Valsalva, and the difference between the two.
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Receiver operator characteristic curves of the abilities of sonographic measurements to differentiate between clinical classifications. (A) Subclinical vs. clinical varicocele; (B) Grade 1 vs. Grade 2 varicocele; (C) Grade 2 vs. Grade 3 varicocele. AUC, area under the curve.
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| Varicocele WHO grade (physical exam) | Best Measurement | Cut-off value (mm) | Sensitivity (%) | Specificity (%) | AUC | | 0 vs. 1-3 | Diameter at rest | 3.0 | 79 | 42 | 0.67 | | 1 vs. 2 | Diameter during Valsalva | 5.7 | 71 | 33 | 0.57 | | 2 vs. 3 | Diameter at rest | 3.6 | 71 | 58 | 0.65 |
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Cut-off values of venous diameter to distinguish between clinical grades of varicocele.
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